=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235849563
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHANG SUH PHARMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/28/2022
-----------------------------------------------------
Last Update Date | 11/28/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 295 VARNUM AVE
-----------------------------------------------------
City | LOWELL
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01854-2134
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 978-788-7479
-----------------------------------------------------
Fax | 978-788-7805
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8 PINE TREE DR
-----------------------------------------------------
City | METHUEN
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01844-1268
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 978-257-4553
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | PH26388
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------